A new health care model

CDPHP's change in how doctors are paid may benefit their patients

Published 11:27 pm, Monday, March 12, 2012

Photo: Paul Buckowski

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Latham Medical Group employees, from left, Rose Gepfert, R.N., Kelly Martin, R.N., and a clinical care coordinator, Kelly Martin, R.N., and a patient care coordinator, Heather Whitcomb, R.N., and a patient care coordinator, Dr. Raymond Carrelle and Iccis Vickery, L.P.N., and a patient care coordinator all take part in a "physician's huddle" at a nursing station in Latham, NY. The huddles allow those involved in a patient's care at the practice to come together to discuss treatment plans. (Paul Buckowski / Times Union) less

Latham Medical Group employees, from left, Rose Gepfert, R.N., Kelly Martin, R.N., and a clinical care coordinator, Kelly Martin, R.N., and a patient care coordinator, Heather Whitcomb, R.N., and a patient care coordinator, Dr. Raymond Carrelle and Iccis Vickery, L.P.N., and a patient care coordinator all take part in a "physician's huddle" at a nursing station in Latham, NY. The huddles allow those involved in a patient's care at the practice to come together to discuss treatment plans. (Paul Buckowski / Times Union) less

Latham Medical Group employees, from left, Rose Gepfert, R.N., Kelly Martin, R.N., and a clinical care coordinator, Kelly Martin, R.N., and a patient care coordinator, Dr. Raymond Carrelle, Iccis Vickery, L.P.N., and a patient care coordinator and Heather Whitcomb, R.N., and a patient care coordinator, all take part in a "physician's huddle" at a nursing station in Latham, NY. The huddles allow those involved in a patient's care at the practice to come together to discuss treatment plans. (Paul Buckowski / Times Union) less

Latham Medical Group employees, from left, Rose Gepfert, R.N., Kelly Martin, R.N., and a clinical care coordinator, Kelly Martin, R.N., and a patient care coordinator, Dr. Raymond Carrelle, Iccis Vickery, L.P.N., and a patient care coordinator and Heather Whitcomb, R.N., and a patient care coordinator, all take part in a "physician's huddle" at a nursing station in Latham, NY. The huddles allow those involved in a patient's care at the practice to come together to discuss treatment plans. (Paul Buckowski / Times Union) less

A quiet revolution is happening in doctors' offices around the Capital Region.

CDPHP, the region's largest insurer, is abandoning the "fee-for-service" payment model for primary care doctors. Instead, the insurer is giving doctors a monthly payment for each CDPHP member — regardless of whether the patient visits the doctor or not.

"Fee-for-service historically has forced docs to reduce the amount of time they spend with each patient because they need to see more patients to meet overhead costs, which are increasing year on year," said Lisa Sasko, director of clinical transformation at CDPHP. "Moving away from fee-for-service allows the docs and the practice to be creative and innovate."

The model encourages physicians to talk with patients by phone and email, host group visits with diabetic or heart patients, and allow physician assistants and nurse practitioners to treat minor cases so doctors can spend more time with complex patients.

The company offers a potential $111,000 bonus for doctors who keep their patients healthy and out of the hospital — a significant salary increase for Capital Region family doctors, who earn $150,000 on average.

After years of testing the model at three physician practices that serve a total of 13,000 patients in the Capital Region, CDPHP said it has been a success: The doctors earned more, the insurance company paid less, and patients were healthier and more satisfied with their care.

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"We found savings in the system," Sasko said.

The market power of CDPHP and the incentive of earning more money has doctors scrambling to participate in the new payment system, which CDPHP calls "Enhanced Primary Care."

Currently, 16 Capital Region practices are involved, and by 2013 it will grow to 73 practices with 384 doctors and 100,000 patients.

So far, doctors have on average earned about $50,000 of the bonus, according to CDPHP. The company says the goal is to stanch the rising costs of health care and make primary care an attractive career choice for doctors.

According to CDPHP's data, the new payment system has saved the company $96 per member annually; hospital admissions declined 15 percent and ER visits declined 9 percent. At the same time, measures of patients' health — including diabetes control and blood pressure control — improved in 15 out of 18 categories.

"We saw it as an opportunity to learn if there was really a better way to do what we do," said Dr. Louis Snitkoff, medical director at CapitalCare, one of the early adopters of the new model.

So far, he said, it is has shown that high-quality care is less expensive.

What is unique about the CDPHP model is that the monthly fee it pays is risk-adjusted based on the patient's health. For example, a doctor receives a monthly payment of $20 for a healthy patient and $50 for a diabetic. CDPHP said no other insurer has tried a risk-adjusted model.

Dr. Raymond Carrelle Jr. said the fee-for-service wasn't working for doctors or patients at his practice. "It didn't matter how well you took care of them, as long as you got them through the door you got paid more. But that was a tough model to keep going because you can only see so many patients a day," said Carrelle, a managing partner with Community Care's Latham Medical Group.

Carrelle saw patients every 15 minutes. "I felt like I was on a hamster wheel — seeing patient, patient, patient," he said.

When CDPHP asked his colleagues to test the new model, they jumped on board.

The company required the medical group, and any practice that participates in the new payment model, to change the way they function.

The practices rearranged their medical records to track diabetic patients and patients with high blood pressure. For example, the system monitors whether diabetes patients get eye screenings, foot exams and food evaluations once a year, and sets goals for blood pressure and cholesterol levels.

The staff learns to work like a team with physician assistants and nurse practitioners, and CDPHP pays a care coordinator to visit the practices one or two times per week to organize the care of the sickest patients.

Carrelle works shorter days and feels like he accomplishes more.

"I feel much more invigorated about what I'm doing," he said. "I think I'm taking better care of people and my patients are happier."

Surveys show patients in the enhanced primary care system are more satisfied, according to CDPHP. "It's been more personable, more thorough," said Tamara Hildenbrandt, a nursing student who accompanies many of her family members on visits to Scotia-Glenville Family Medicine, which participates in CDPHP's new model. Hildenbrandt has been a patient there since she was 13. "They don't pawn you off on a specialist," she said. "They coordinate your care and make sure they are thorough before they farm you out."

The incentives of CDPHP's new model discourage doctors from sending patients to the hospital or specialists, but Sasko said patients will get specialized care when they need it.

"Decreasing any utilization that is necessary is not what this program is about, and providers do not do that," Sasko said. "That's not what they went to schools of medicine for; that's not why they are in this business."

The CDPHP care coordinators that visit doctors' offices do not act as gatekeepers. Doctors and patients interviewed for this story said the coordinators are advocates.

Ginny Weeks, a retired state worker from Glenmont, was the primary caregiver for her father before he died in August. Her dad, Forrest Weeks, had Alzheimer's disease and had suffered a stroke. His needs were intense, and Weeks often called on "Jessica" for help.

Jessica Rico was the care coordinator at Community Care's Albany Family Practice Group. She helped Weeks get a walker and a reaching device. She instructed Weeks to install extra smoke detectors and pull up throw rugs to keep her dad safe at home, and Rico worked with a neurologist to teach Weeks tips for managing her father's Alzheimer's-related behaviors.

"I felt like I wasn't home alone," Weeks said. "I had Jessica working for me."

Those models give doctors extra payments to coordinate patient care on top of fee-for-service payments, but Sasko said they do not address the root cause: the volume churn driven by fee-for-service payments.

"This is a game-changing play that CDPHP embarked on four years ago, and we urge others to participate," she said. "We need to work together on this."